Using the Tidal Model of Mental Health Nursing in Psycho-Geriatrics - Case Study Example

Using the Tidal Model of Mental Health Nursing in Psycho-Geriatrics Introduction Mental illness presents both the client and the carer with challenges that are unique to the particular manifestation at hand. The experiences of each patient are unique; even when the comparison is amongst patients with similar backgrounds and conditions. Age, personal experiences, commitments, stressors and resources available hold key elements to both, understanding the illness and the process of recovery from it. The Nurse interacts with these clients in far greater detail than other professional carers; and thus plays an important role in diagnosis, monitoring treatment and affecting change for the client. As a link between the doctor and client, the nurse needs to be aware of minute details that could play significant roles in treatment and recovery. The present case is of an 80 year old female within an APATT based community setting, who has a history of mental illness from before the present incidence. The Tidal Model of Care shall be used in the process of assessment and treatment to enable recovery. The Role of the Professional Nurse and Its Impact on Patient Care As a link between the client and doctor, the nurse plays a key role at each stage of treatment. The RCN defines Nursing as “the use of clinical judgment in the provision of care to enabled people to improve, maintain or recover health; to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death” (RCN, 2003). The professional nurse has a range of responsibilities and roles (GMC, 1995) that parallel in importance to that of the doctor. Irrespective of the reasons for this growth in the responsibilities shouldered by the nursing community; an evident fact is that nursing now has a strong impact on the process of care and recovery experienced by a client. It is thus necessary to establish processes that are most beneficial, and to develop a perspective that allows the nurse to interpret the process of treatment to the specific needs of the client. The Tidal Model of Care provides just this philosophical approach to mental health nursing. The Tidal Model A nursing model has been defined as “A collection of interrelated concepts that provides direction for nursing practice; research and education that approaches the nursing process in a logical, systematic way and influences the very data the nurse collects.” (Rambo, 1984). The Tidal Model of Mental Health Nursing was suggested by Professors Phil Barker, Chris Stevenson and Poppy Buchanan-Barker amongst others. The basis for the approach is the continuous change in all individuals at all times Kitson, 1999. The Tidal Model attempts to make sense of the personal experiences of people, and the role these experiences play in recovery. It believes that a client is capable of leading their own recovery instead of being directed by professionals (Barkway, 2009). The model is based on 6 philosophical assumptions: Barker (2008). 1. Virtue of curiosity: Genuine curiosity can help the professional learn about experiences central to the clients’ illness and recovery. 2. Power of resourcefulness: Available resources need to be identified and used effectively to aid recovery. 3. Respect for the person’s wishes: Patients are cognisant of their own needs and abilities. It is important to listen to them. 4. Paradox of crisis: Every crisis situation can be used as a pointer to the needs of the individual; and can be used to fuel eventual recovery. 5. All goals must belong to the person: Ownership over recovery goals gives the client a feeling of control over the direction and pace of recovery; and is important in the long term maintenance of health. 6. Pursuing elegance: It is easy to be overrun by complex and tedious treatments. The most optimal treatment is often the one that requires the least effort in covering all chosen goals. These assumptions have become the base for the development of a set of 10 commitments that a nurse using the Tidal Model makes to the task of nursing. Each of these commitments is associated with two competencies; and thus the nurse is expected to have a total of 20 competencies. Commitments and Competencies Each individual has three domains – the Self, the World and the Others. Life experiences including the thoughts, actions and perceptions of the individual affect mental well being. The professional needs to make a few commitments to the process of helping the client live most fruitfully in all these three so that recovery is all rounded. In order to do this, there are certain competencies that the professional requires to develop. Research has identified 10 commitments on part of the professional nurse, and two competencies associated with each of these commitments. These are: 1. Value the voice: The personal account of the client is the best source of information about her/his experiences, and therefore should be recorded in their own words to keep the flavour of those experiences through the recovery process. a. Competency 1: The capacity to listen actively. b. Competency 2: Helping the person record the story in her/his own words. 2. Respect the language: Using the metaphors and grammar of the client is the best way to record their exact experiences; and it also conveys the respect of the practionner for these experiences. a. Competency 3: Help the person express in her/his own language. b. Competency 4: Help the client express her/his understanding of particular experiences using personal stories, anecdotes, similes or metaphors. 3. Develop genuine curiosity: Genuine curiosity involves not only picking up details of the problem, but also listening to the unique account of experiences that the client considers important. a. Competency 5: Ask for clarification of particulars and examples. b. Competency 6: Help in unfolding the story at the person’s own rate. 4. Become the apprentice: Accept that the client is the expert on his/her own experiences, and learn from them about what possibilities of recovery are more valuable (Szasz, 2000). a. Competency 7: Develop a care plan based on the expressed needs of the person. b. Competency 8: Help in identifying specific problems of living, and solutions. 5. Use the available toolkit: Instead of focusing on what normally works; the practioner is expected to focus on what has worked for the individual; or what they think may work. a. Competency 9: Help develop awareness of what works for or against them b. Competency 10: Identify what specific people can or might be able to do to help. 6. Craft the step beyond: Discussing and planning recovery step by step and envisioning it can help the client gain ownership over the process. a. Competency 11: Help identify the kind of change that would represent stepping in the direction of recovery. b. Competency 12: Help identify immediate goals. 7. Give the gift of time: Most professionals do not spend too much time with a patient (Jonsson, 2005). It is important to invest the time required by the client, and the practitioner for the best quality treatment (Derrida, 1992). a. Competency 13: Help develop the awareness that time is being dedicated b. Competency 14: Acknowledge the value of the time given to assessment and care. 8. Reveal personal wisdom: Wisdom gained through the individuals’ experiences can be used as a force to guide them through the process of recovery. The professional needs to acknowledge the power of this wisdom (Barker, 2002). a. Competency 15: Help identify personal strengths and weaknesses. b. Competency 16: Help develop self-belief. 9. Know that change is constant: The continually changing circumstances can be harnessed to promote growth; and it is the practionner’s task to help in making choices that will lead to growth and thus, recovery. a. Competency 17: Help develop awareness of changes. b. Competency 18: Help become aware of how the self, others or events influence changes. 10. Be transparent: Transparency requires collaborating with the client on assessments and making care plans; helping them understand the processes and taking feedback from them actively. a. Competency 19: Aim to ensure that the person is aware of the purpose of all processes. b. Competency 20: Ensures that the person has copies of all documents. Presented Case It was proposed that the Tidal Model of Care be applied to a case presented in the community. The client was an 80 year old female – Mrs. N – who entered care on the 17th of March 2011. Her presenting complaints included depression combined with anxiety and panic attacks that had persisted for some time. Medical history showed that a year previously she had been under treatment for the same; but with only partial efficacy. The same private practionner had referred her to the APATT. Treatment was to be in a community setting since the client was able to keep up with her daily routine. Diagnosis showed that she had symptoms of tiredness, loss of interest in ADL activities, and had IBS and weight loss (5 lbs) in the period from December 2010. There is an also record of low mood. These symptoms are consistent with the criteria for depression (ICD – 10). In 2009, the client had been diagnosed with burning mouth syndrome and phantom jaw pain. The initial assessment also included a detailed personal history; taken over a number of interviews. Simple physical examination of cardiovascular and neurological functioning was conducted in order to ensure that there were no underlying biological reasons for the symptoms. The client was kept informed and involved in each step of this process. At any point where the patient was scared or hesitant, she was given support and time so she could prepare herself for the assessment (Dziopa & Ahern, 2009). Assessment of the patient’s psycho-social development and pre-morbid personality was also conducted; as was the assessment of her current circumstances (Davies, 1997). This assessment revealed that the client had been diagnosed with depression in the past, but no medical treatment was given; and she had chosen to become involved in social work at the point. There was also a family history of mood related illnesses in her father and uncles. Application of the Tidal Model During assessment, there was a genuine attempt made to follow the first Commitment; and record the experiences of the client in her own words; and allow her to guide the process in identifying significant aspects of her history. This used the 2nd competency. At this point, there was no diagnosis, or clinical interpretation; but a record of significant events (as identified by the client and probed for by the nurse) was made for future use. There was an attempt to fulfil the 1st competency here. The client revealed that her first diagnosis of depression was preceded by infidelity by her husband, which led to relationship problems. This was in 1970, and she chose to stay in her marriage and cope with the experience by focusing on raising her sons, being involved with community work, and being involved with family. In the process of documenting these events and choices; commitment 2 was used and a record of the client’s experiences was made in her own words and metaphors (Barker & Barker, 2008). She describes the period after her husband’s affair as ‘difficult’ as her husband’s behaviour ‘hung like a black cloud’ over everything else. Things were brought to another head in 2006, when her husband confessed to another affair. In spite of her having chosen to stay in the marriage her husband still treats her with disrespect. This is even though she helps him deal with his weak bladder and fecal incontinence. The client feels like her life has been ‘wasted’, since that she ‘feels like walking out of the marriage’. The nurse took full effort to use the 3rd and 4th competencies when recording the case and the client’s experiences. Commitment 3 requires the nurse to show genuine concern about these experiences, and to try and understand their significance in the life of the client. Her motivations to have acted thus were explored, as was her own history from medical as well as non medical points of view. The client described the Navigating Life sessions she attended under a psychologist’s care. At this point she also mentioned that her father had been diagnosed with depression and had been treated with psychiatric hospital admissions as well as ECT treatment. Two of her maternal uncles were lost to suicide as well. Competency 6 was used when getting this information. Thus, there is a family history of mood disorders, and difficult experiences associated with the same. This explains her motivation to continue her life as normally as possible. As part of fulfilling commitment 4; the client was not second guessed in the process of interpreting her case history. Using competency 7, she was also consulted in detail about what she felt would be helpful as part of her treatment; and what life changes would help her improve the quality of her experiences. Commitment 5 requires that the nurse uses available information to identify the most optimal means to recovery. This involved using competency 9 and identifying what has worked for the patient in the past, and what has not. Since the client has had episodes similar to the present one before; it was possible to eliminate the therapeutic techniques that have not worked for the client in the past (Magee, 2010). In fulfilling the 6th commitment; and helping the client envision the steps to recovery, it was found that she needed to be helped to put the past behind her, and step in to the future without the baggage of the failed relationship that she was still carrying. Obtaining closure with pain from the past was considered important for recovery in this case; and the client showed desire to live without the pain and thus divert her attention from the neurosis to a fruitful existence (Berg & Halberg, 2000). The 7th commitment requires the nurse to spend as much time as is required to understand and assess the situation that the client finds herself in. The nurse is also expected to spend time with the client helping her understand the process of her recovery, and taking decisions for the same. This was maintained by using competency 13 and being patient in gathering history; and in helping the client take decisions for the future. She was given as much time and company as she required in moving through the process of recovery. The client herself was well aware of what she required to change her world-view. She wished to leave her husband and wanted to have a fruitful life. Her wisdom needed to be tapped so that she could feel the ownership of her decisions and the strength that comes with it. Making this happen was in keeping with the 8th commitment and was done using the 16th competency. At the stage in life that the client finds herself, change can feel very big and difficult. She needs to be reminded that change would happen regardless, and that she has the ability to harness the capacity for change in each situation for the better. Every threshold gives her choices, and regardless of her previous choices, she can now explore her choices afresh and take decisions accordingly. Helping her through this process would fulfill the 9th commitment by using the 17th and 18th competencies. Throughout the process, the client was kept on the loop, and all decisions were deferred to her wishes. She was involved in planning the process for her recovery. This transparency was maintained so that the 10th commitment could be fulfilled. The 19th and 20th competencies were used in order to achieve this. Recommendations Certain recommendations are placed on record so that they are accessible to both, the professional careers involved in the case of Mrs. N and the client herself. The client needs to remove herself from the domination that she has allowed in her relationship with her husband. It is most important that she emotionally removes herself from his control, so that his behavior cannot affect her further. Physical distance from the husband is a choice that the client needs to decide about; as it is a very huge step; especially considering her age. It is at least possible that she employs a career who can accompany him to the clinic and care for his medical needs, so that she is not required to have abrasive contact with him. It is necessary that she continues to have positive relationships with her sons, as she cherishes these relationships. It may be required that she inform her sons about changes that she plans to make in her own life. Only her own wisdom can guide her about whether to reveal the past to the sons; but it is recommended that she explore the possibility in her mind, in case they need to understand the reasons for her needing to take major decisions. If the client so wishes, she should be offered professional help in making peace with her past experiences and the decisions she made in context to those experiences. She should be helped to appreciate her own abilities, qualities and strengths and cherish herself. It is suggested that she would benefit from being helped with exploring some fruitful way in which she can use her talents and time in society. This would help her overcome the pull of negative experiences, and substitute them with positive ones. It would also help her in moving from a place in her mind where she views her life as ‘wasted’ to one where she views her life as ‘useful’. It is hoped that in resolving the emotional problems the client finds herself in, her physical symptoms will also wane. Conclusion Mental health nursing is one of the most complex and demanding areas of nursing. The key task of the mental health nurse is to take care of patients and their families. This involves having both good communication skills and good knowledge about medication (Roper et al, 2000). The nurses need to work in collaboration with doctors, family caregivers and other members of the medical team to bring the patient back to health. If they acknowledge the patient’s own potential for recovery, and help them actualise it, the client is likely to have a better quality of life post – treatment (Quaglietti et al, 2004). References Barker, P. & Barker, P.J., (2008). The Tidal Commitments: extending the value base of mental health recovery. Journal of Psychiatric and Mental Health Nursing, Vol. 15, (2), pp. 93–100. Barkway, P., (2005). Theories on Mental Health and Nursing. Psychiatric and Mental Health Nursing (2 ed.). Mosby. pp. 119–134. Berg, A. and Hallberg, I.R. (2000). Psychiatric nurses lived experiences of working with inpatient care on a general team psychiatric ward. Journal of Psychiatric & Mental Health Nursing 7.4: pp. 323-333. Davies, T., (1997). ABC of mental health. Mental health assessment. [online]. Available from: http://www.bmj.com/content/314/7093/1536.full. Dziopa, F, and Ahern, K. (2009). What makes a quality therapeutic relationship in psychiatric/mental health nursing: A review of the research literature. Internet Journal of Advanced Nursing Practice Volume 10 Issue 1, pp.1-19. General Medical Council, (1995). Confidentiality. London: GMC General Medical Council, (1995). Duties of a doctor. London: GMC Kitson, A., (1999). The essence of nursing. Nursing Standard, 13 (23), pp. 42-46. Magee, M., (2010). Barriers to Effective Communication in Nursing. [Online] Available from: http://www.ehow.com/list_6797926_barriers-effective-communication-nursing.html. Maguire, P. and Pitceathly, C., (2004). Key communication skills and how to acquire them Cancer Research UK Psychological Medicine Group. Christie Hospital NHS Trust: Manchester. Quaglietti, S., Blum, L. & Ellis, V. (2004). The Role of the Adult Nurse Practitioner in Palliative Care. Journal of Hospice and Palliative Nursing. Vol. 6, (4), pp. 209-214. Roper, N., Logan, W.W. and Tierney, A.J., (2000). The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. Edinburgh: Elsevier Health Sciences. Royal College of Nursing, (2005). Confidentiality. RCN Guidance for occupational health nurses. London: RCN. Royal College of Nursing, (2003). Defining nursing. London: RCN. United Kingdom Government, (1997). Nurses, Midwives and Health Visitors Act. London: HMSO. Appendix: Case Papers of the Discussed Case Mrs Neurosis is an 80yr.old woman who suffers anxiety, panic and depressive problems. She has been treated by a private psychiatrist Dr Sigmund for “a couple of years, a year or so ago”. Recently Mrs Neurosis contacted her psychiatrists office, the good Dr declined to re-commence therapy with her stating “he had done all he could do” which was kindly relayed via his receptionist, who also provided APATT contact details and encouraged Mrs N to seek help from same. Mrs Neurosis was very happy she was going to get some help and phoned APATT on 15/3/2011. Screening Description on Triage: Low mood, Anxiety, Co-morbidities Presenting Complaints (on Ax 17/3/11): Duration: Feeling physically tired Decreased interest in activities Decreased interest in attending ADLs Early morning wakening Sometimes */c panic attacks Weight loss (5kg) since Christmas Anxiety related to physical ailments: "Burning mouth syndrome" - Diagnosed 2009 (+phantom jaw pain) IBS – Diagnosed 2010 Since Dec 2010 Increase 2/52 Precipitating Factors: Relationship problems; long term since 1970 History of Relationship Problems (Incidence wise): 1970 Discovered husband having affair- sad, teary. Diagnosed by GP with Depression, no treatment or medication prescribed. Next 30yrs worked in Vet surgery (husbands practice). Did voluntary work. Devoted mother, raised 3xsons. Coped with life, but "black cloud over husbands affair always there". Described these 30yrs as wasted, however maintained family, work, community interest and mood was "good". 2000 Retired, continued volunteer work & tai chi, rated mood 5/10, feels retired too early (Age: 70yrs). 2006 Similar to 1970, informed by husband of “mistress”: affair was ongoing. Mood- "rock bottom". Current Mrs N’s husband suffers bladder/bowel problem. Mrs N attends in/out catheter care BD 0700 & 2300hrs, husband is capable but insists Mrs N attends. Husband faecally incontinent, which Mrs N cleans up. Mrs N feels husband "puts [her] down" (how he speaks). Mrs N states she would like to be "on..[her] own". Past Psychiatric History: Long standing Hx panic attacks Depression (untreated 1970) 2009 Diagnosed */c Generalised Anxiety Disorder (ICD-10) Dr Sigmund (Psychiatrist) prescribed Mirtazapine (Avanza) 15mg nocte Dr Talacko (ENT) recommended Amitriptyline, Dr Sigmund disagreed, recommended Quetiapine (Seroquel) 12.5mg- ceased after 2xdose due to sedation +++, went back on Avanza, contd past 2yrs. December 2010 GP referral Navigating Life x3 sessions */c Psychologist attended Current Diagnosis: Ax by consultant psychiatrist 31/3/11- F33.01 Recurrent Depressive Disorder, current episode mild, with somatic syndrome F41.0 Panic Disorder (episodic paroxysmal anxiety) Ego Dystonic State Medical History: Hypertension: episodical Hernia/rectal prolapse surgical Rx (Delorme’s): 2006 Reflux: 2007 Mouth/Jaw Pain: 2007 Burning Mouth Syndrome: 2009 (Dr Talacko Melb) Facial Rash – Possibly Sjorgen’s Syndrome NAD: 2010 IBS: 2010 Current Medications (on Ax 17/3/11): Name Dose Commencement Date Frequency Reason Ceased Avanza 15mg 2009 Nocte Myoclonic jerks Inderal 30mg BD Coversyl 8mg Mane Nexium 20mg Mane Immodium For IBS Prn Vitamin, D,B & C OD Personal History including Premorbid Personality: Mrs N was born in Sydney, she was only child, describes parents as loving. Early school years reported as lonely, she was shy. Post high school attended University, studied vet science, where she met husband. Married in 1955, moved to Numurkah, where John established vet practice. They had 3 sons, Alan, Ian and Phillip and 5 grandchildren. As far as Mrs N knows her sons arent aware of their father’s affairs and she states “[she] hope they dont know”. MENTAL STATE EXAMINATION APPEARANCE Frail, thin lady, white hair cut short with light perm. Wearing cardigan & trousers. Hygiene attended, no make-up or jewellery. Clothing clean, however appeared well worn. BEHAVIOUR Sat relaxed on kitchen chair, hands held together on table. Thought carefully before answering, polite, cooperative, no psychomotor agitation. Slight hand tremor. Slight anxiety husband may overhear when discussing affair. Observed to rise out of chair with ease, ambulated without unsteadiness. MOOD Feels mood is low, worse of a morning. Reports mood and feeling of "dullness" improves in afternoon. Stated our talk today helped. AFFECT Congruent, appropriate to content, fragile. THOUGHT Form- NFTD evident. Content- Expressed sadness of what she described as "wasted years" after the 1st affair was brought to her attention. Marriage never the same "always there, never goes away". Second time (with same woman)- now knows affair never ended- small community, having to live with everyone knowing. Now husband needs her because of poor health, feels no love- denies physical or verbal abuse, but acknowledges emotional abuse. Hates "Thursday" as she was informed of affair (2nd time) on a Thursday. Would like to be "on my own" and not in a carer role. COGNITION Intact 30/30 MMSE EMOTIONAL GDS 11/15 SLEEP Poor, midnight - 0500hrs. APPETITE Poor, lost 5kg in past 2months, difficulty eating due to IBS, jaw/mouth problems. RISK States she has thoughts life is not worth living but denies plan or intent to harm self or others. INSIGHT Intact JUDGEMENT Intact Clinical Problems Interventions Timeframe Person Responsible 1.Depressed Mood Review of medication and psychiatrist to review ASAP Dr Alby Elias C/M 2. Relationship problems Opportunity to discuss past history of husbands affairs ongoing client psychologist 3. physical problems Review by GP / specialist ongoing Client GP 4.Social isolation Link back into the community ongoing Client C/M 5.Carer Role Carer stress Interventions to reduce carer burden ASAP C/M Client Read More